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State of tobacco control in Nebraska 04 20-11 2


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Preventing and reducing tobacco use in Nebraska: An overview.

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State of tobacco control in Nebraska 04 20-11 2

  1. 1. 1<br />The State of Tobacco<br />Control in Nebraska:<br />One Economist’s Perspective<br />Frank J. Chaloupka<br />University of Illinois at Chicago<br />Change – Challenge - Progress<br />Tobacco Free Nebraska State Conference<br />Lincoln, NE, April 20, 2011<br />
  2. 2. 2<br />Overview<br />MPOWER Framework<br />“Monitor” the tobacco epidemic<br />“Protect” non-smokers<br />“Offer” help to quit<br />“Warn” about the harms<br />“Enforce” marketing bans<br />“Raise” taxes<br />Focus on:<br />Where we’ve been<br />Where we are now<br />Where we can go<br />
  3. 3. 3<br />Monitor<br />
  4. 4. 4<br />Source: TBOT<br />
  5. 5. 5<br />Source: TBOT<br />
  6. 6. 6<br />Source: BRFSS<br />
  7. 7. 7<br />Source: BRFSS<br />
  8. 8. 8<br />Source: YRBS, YTS; some data points interpolated<br />
  9. 9. 9<br />Source: YRBS, YTS; some data points interpolated<br />
  10. 10. 10<br />Source: BRFSS<br />
  11. 11. 11<br />Source: BRFSS<br />
  12. 12. 12<br />Most Recent Scientific Evidence: Active Smoking<br />Source: adapted by CTLT from the U.S. Surgeon General’s Report. (2004); from JHBSPH/IGTC on-line course<br />
  13. 13. 13<br />Tobacco Use in Nebraska<br />Where have we been?<br />Slow but steady progress in reducing tobacco use in NE<br />Adult & youth smoking prevalence, cigarette consumption falling over time<br />Declines comparable to US and neighbors<br />Sharper declines in sales in some neighboring states in recent years<br />
  14. 14. 14<br />Tobacco Use in Nebraska<br />Where are we?<br />Much remains to be done:<br />Over 220,000 adults currently smoke<br />Persistent racial/ethnic, socio-economic, and gender disparities<br />Over 20,000 high school kids are likely currently smoking<br />Many non-smokers exposed to tobacco smoke at home, in workplaces <br />~2,300 premature deaths each year caused by smoking<br />
  15. 15. 15<br />Tobacco Use in Nebraska<br />Where are we?<br />Considerable economic costs<br />Over $750 million spent annually to treat diseases caused by smoking<br />Significant fraction paid by public health insurance programs<br />Another $625 million in lost productivity from premature deaths caused by smoking<br />
  16. 16. 16<br />Tobacco Use in Nebraska<br />Where can we go?<br />Much remains to be done:<br />Estimate that ~105,000 current youth will eventually take up smoking<br />As many as 160,000 current Nebraskans will die prematurely from smoking<br />Health and economic burden greatest among poor, less educated<br />Effective interventions exist<br />
  17. 17. 17<br />Protect<br />
  18. 18. 18<br />Diseases and Adverse Health Effects Caused by SHS<br />Image source: adapted by CTLT from U.S. Surgeon General’s Report. (2006); from JHBSPH/IGTC on-line course.<br />
  19. 19. 19<br />State Smoke-Free Air Policies<br />Source: ImpacTeen Project<br />
  20. 20. 20<br />Local Smoke-Free Air Policies<br />Source: Americans for NonSmokers’ Rights Foundation<br />
  21. 21. 21<br />Smoke-Free Air Policies<br />Where have we been?<br />Until recently<br />Relatively weak state policies limiting smoking in public places, workplaces<br />
  22. 22. 22<br />Smoke-Free Air Policies<br />Where are we now?<br />NE Smoke-Free Air Act adopted February 2008<br />Effective June, 2009<br />100% smoke free workplaces, bars, restaurants, gambling establishments, and other public places<br />Among most comprehensive state policies<br />CO (1/08), IA (7/08), KS (7/10) adopt similar policies, but not as comprehensive<br />
  23. 23. 23<br />State &Local Smoke-Free Air Policies<br />Source: Americans for NonSmokers’ Rights Foundation<br />
  24. 24. 24<br />Impact of Smoke-Free Air Policies<br />Source: Chaloupka 2010<br />
  25. 25. 25<br />Impact of Smoke-Free Air Policies<br />Source: Chaloupka 2010<br />
  26. 26. 26<br />Smoke-Free Air Policies<br />Where are we now?<br />Compliance improving over time<br />SFA policies generally self-enforcing<br />No negative economic impact<br />Any losses due to reduced patronage offset (or more) by increased patronage from non-smokers<br />Reduces other business costs<br />Cleaning costs, lost productivity<br />
  27. 27. 27<br />Economic Impact of IL SFA Policy<br />Restaurant Revenues<br />Source: Tauras & Chaloupka, in progress<br />
  28. 28. 28<br />Economic Impact of IL SFA Policy<br />Bar Revenues<br />Source: Tauras & Chaloupka, in progress<br />
  29. 29. 29<br />Economic Impact of IL SFA Policy<br />Casino Patrons per Month<br />Source: Tauras & Chaloupka, in progress<br />
  30. 30. 30<br />Smoke-Free Air Policies<br />Where can we go?<br />Extend protections to new venues<br />Parks, beaches, outdoor dining, other outdoor venues<br />Multi-unit housing<br />Cars with children <br />Various localities have adopted policies covering outdoor settings<br />
  31. 31. 31<br />Offer & Warn<br />
  32. 32. 32<br />Comprehensive Programs<br />General aims:<br />Prevent initiation of tobacco use among young<br />Increased prices, reduced access<br />Increased antitobacco messages, reduced protobacco<br />Promote cessation among young adults, adults<br />Better access to cessation services<br />Increased prices and strong smoke-free policies<br />Increased antitobacco messages, reduced protobacco<br />Eliminate exposure to secondhand smoke<br />Strong smoke-free policies<br />Strengthened anti-smoking norms<br />Identify and eliminate disparities<br />Intertwined with others; need for targeted approaches<br />Source: USDHHS, 2000; CDC 2007<br />
  33. 33. 33<br />Comprehensive Programs<br />Components of a comprehensive program:<br />State and community interventions<br />Support for policy development and implementation<br />Efforts to strengthen norms against tobacco<br />Targeted efforts to reduce youth tobacco use, disparities<br />Health communication interventions<br />Mass-media countermarketing campaigns<br />Efforts to replace tobacco industry sponsorship/promotion<br />Targeted messaging/delivery<br />Cessation interventions<br />Array of policy, health system, and population-based measures <br />Surveillance and Evaluation<br />Administration and Management<br />Source: USDHHS, 2000; CDC 2007<br />
  34. 34. 34<br />State Tobacco Control Program<br />Where have we been?<br />Funding since 1994 for state tobacco control program<br />CDC program funding<br />Private funds (RWJF, ALF)<br />State Master Settlement Agreement revenues since 2000<br />In early 2000s, among better funded state programs<br />
  35. 35. 35<br />Source: ImpacTeen Project, CDC<br />
  36. 36. 36<br />Comprehensive Programs<br />Impact of state program funding<br />Increased funding associated with:<br />Reductions in overall cigarette sales<br />Lower youth smoking prevalence<br />Lower adult smoking prevalence<br />Increased interest in quitting, successful quitting<br />Much of impact results from large scale mass-media anti-smoking campaigns<br />
  37. 37. 37<br />Source: ImpacTeen Project, UIC; YRBS<br />
  38. 38. 38<br />Program Funding<br />Source: Tobacco Free Kids, 2010<br />
  39. 39. 39<br />State Tobacco Control Program<br />Where are we now?<br />Significant reductions in state funding in recent years<br />From $7 million in FY03 to $2.9 million in current fiscal year<br />Continued funding from CDC for state program ($1.8 million in current fiscal year)<br />Additional funding from Communities Putting Prevention to Work, American Recovery and Reinvestment Act, and Prevention and Public Health Fund grants (~$1.8 million in FY10-11)<br />
  40. 40. 40<br />Program Funding<br />Source: Tobacco Free Kids, 2010<br />
  41. 41. 41<br />Program Funding<br />Source: ImpacTeen project, 2010<br />
  42. 42. 42<br />State Tobacco Control Program<br />Where are we now?<br />Significant demand for cessation<br />~50% of smokers indicate making quit attempt in past year<br />Nearly 2/3 indicate interest in quitting<br />State support minimal<br />11% of CDC recommended funding for cessation in FY09, likely less now<br />Medicaid coverage for NRT, Chantix, Zyban (with co-pay)<br />No coverage for individual/group counseling<br />
  43. 43. 43<br />State Tobacco Control Program<br />Where are we now?<br />Few smokers using the state’s Quitline<br />
  44. 44. 44<br />State Tobacco Control Program<br />Where are we now?<br />Relatively good exposure to anti-smoking media campaign ads<br />Some anti-smoking messages coming from national campaigns<br />
  45. 45. 45<br />State Tobacco Control Program<br />Where can we go?<br />Fund program activities at levels recommended by CDC<br />$9.9m for state/community interventions<br />$6.2m for cessation interventions<br />$3.8m for health communication interventions<br />$2.0m for surveillance/evaluation<br />$1.0m for management/administration<br />$22.9m total<br />
  46. 46. 46<br />Enforce<br />
  47. 47. 47<br />Tobacco Marketing<br />Marketing Strategies – the 4 P’s:<br />Product – design, packaging<br />Price – including price promotions<br />Place – availability, accessibility<br />Promotion – advertising, sponsorship, etc.<br />Most effective campaigns are well-integrated across different dimensions of marketing<br />Source: NCI Monograph 19<br />
  48. 48. 48<br />Tobacco Company Marketing<br />Where have we been?<br />Tobacco company marketing pervasive<br />Grew rapidly over time<br />Companies adapt quickly to constraints (e.g. TV/radio ad ban, MSA limits)<br />Change in focus over time<br />State/local restrictions pre-empted by federal legislation<br />
  49. 49. 49<br />Source: author’s calculations from data reported in FTC (2009)<br />
  50. 50. 50<br />Source: author’s calculations from data reported in FTC (2009)<br />
  51. 51.
  52. 52.
  53. 53. 53<br />Price-Related Marketing:Price Discounts<br />
  54. 54. 54<br />Price-Related Marketing:Retail Value Added - product<br />
  55. 55. 55<br />Price-Related Marketing:Coupons<br />
  56. 56. 56<br />Price-Related Marketing:Other Value Added<br />
  57. 57. Tobacco Industry Marketing vs. TobaccoControl Spending (in millions of dollars) – <br />United States, 1986-2005<br />Source: FTC 2005 and Project ImpactTEEN; data are in July 2007 dollars.<br />
  58. 58. 58<br />Tobacco Company Marketing<br />Where are we now?<br />Federal TV/radio ad ban<br />MSA restrictions<br />Outdoor, transit, sponsorships, branded merchandise, etc.<br />
  59. 59. 59<br />Tobacco Company Marketing<br />Where are we now?<br />Significant changes in tobacco industry<br />Consolidation of tobacco companies<br />Emergence of variety of new tobacco products<br />Brand extensions<br />Concentration of marketing effort on fewer and fewer brands<br />
  60. 60.
  61. 61. 61<br />
  62. 62. 62<br />
  63. 63. 63<br />Tobacco Company Marketing<br />Where are we now?<br />Family Smoking Prevention and Tobacco Control Act, 2009<br />Gives FDA authority to regulate tobacco products<br />Candy and fruit flavored cigarettes banned 9/22/09<br />Excludes menthol flavored cigarettes<br />Doesn’t covered other flavored products (small cigarettes, cigarillos, smokeless,….)<br />
  64. 64. 64<br />Tobacco Company Marketing<br />Where are we now?<br />FDA regulation<br />Brand specific disclosure of product constituents required January 2010<br />Restrictions on sale and marketing to youth, April 2010<br />Ban on misleading descriptors, July 2010<br />
  65. 65. Product Labeling: “Replacement” Descriptors<br />
  66. 66. 66<br />Tobacco Company Marketing<br />Where are we now?<br />FDA regulation<br />New warning labels:<br />On smokeless products, July 2010<br />On cigarettes, October 2012<br />
  67. 67.
  68. 68.
  69. 69. Canada <br />2000<br />Singapore<br /> 2004<br />Brazil<br />2002<br />Jordan<br />2005<br />Venezuela<br />2005<br />Thailand<br />2005<br />Uruguay <br />2006<br />Chile<br />2006<br />Hong Kong<br />2007<br />UK<br />2008<br />Belgium<br />2007<br />Australia<br />2006<br />
  70. 70. Brunei<br />2008<br />New Zealand<br />2008<br />Romania<br />2008<br />Egypt<br />2008<br />Iran 2009<br />Cook Islands<br />2008<br />Peru<br />2009<br />Malaysia<br />2009<br />
  71. 71. 71<br />Tobacco Company Marketing<br />Where can we go?<br />FDA regulation<br />Eliminates federal pre-emption of stronger state, local restrictions on tobacco company marketing<br />Comprehensive marketing bans possible?<br />Evidence that comprehensive bans lead to significant reductions in tobacco use<br />
  72. 72. Comprehensive advertising bans reduce cigarette consumptionConsumption trends in countries with such bans vs. those with no bans(n=102 countries)<br />Source: Saffer, 2000<br />
  73. 73. 73<br />Minimum Pricing Policies<br />As of 12/31/09:<br />25 states with minimum pricing policies<br />Typically mix of minimum markups to wholesale and retail prices<br />Median wholesale markup 4% (4.75% in NE)<br />Median retail markup 8% (8% in NE)<br />7 states (including Nebraska) prohibit use of price promotions in minimum price calculation<br />Little impact on actual retail prices<br />Greater impact where promotions excluded<br />Sources: CDC, 2010; Feighery, et al., 2005<br />
  74. 74. 74<br />Raise<br />
  75. 75. 75<br />Cigarette Taxation in NE<br />Nebraska first adopted cigarette tax in 1947<br />3 cents per pack<br />Last increase to 64 cents per pack in 2002<br />About 10% above US average, 17th highest at the time<br />
  76. 76. 76<br />Tobacco Taxation<br />Where have we been?<br /><ul><li>Federal cigarette tax
  77. 77. Specific (per unit) excise tax, initially adopted in 1864
  78. 78. Raised during war time/lowered during peace time
  79. 79. Set at 8 cents per pack in 1951; doubled 1983
  80. 80. Eventually raised to 39 cents per pack in 2002
  81. 81. Less than 60% of inflation adjusted value of 1951 tax
  82. 82. Significant increase – 61.66 cents – April 1, 2009
  83. 83. Earmarked for S-CHIP expansion</li></ul>Other tobacco products taxes at similar rates<br />
  84. 84. 77<br />Tobacco Taxation<br />Where have we been?<br /><ul><li>Other state cigarette taxes
  85. 85. First adopted by IA in 1921;
  86. 86. NC last to adopt in 1969
  87. 87. Specific excise tax in all states
  88. 88. All but PA tax other tobacco products
  89. 89. Mostly ad valorem (percentage of price) taxes</li></li></ul><li>78<br />Taxes, Prices and Tobacco Use<br />Increases in tobacco product taxes and prices:<br />Induce current users to try to quit<br />Many will be successful in long term<br />Keep former users from restarting<br />Prevent potential users from starting<br />Particularly effective in preventing transition from experimentation to regular use<br />Reduce consumption among those who continue to use<br />Lead to other changes in tobacco use behavior, including substitution to cheaper products or brands, changes in buying behavior, and compensation<br />
  90. 90. 79<br />Source: Tax Burden on Tobacco, 2009, and author’s calculations<br />
  91. 91. 80<br />Source: Tax Burden on Tobacco, 2011, and author’s calculations<br />
  92. 92. 81<br />Source: NHIS, Tax Burden on Tobacco, 2009, and author’s calculations<br />Note: green data points for prevalence are interpolated assuming linear trend<br />
  93. 93. 82<br />Source: BRFSS, Tax Burden on Tobacco, 2011, and author’s calculations<br />
  94. 94. 83<br />Source: MTF, Tax Burden on Tobacco, 2009, and author’s calculations<br />
  95. 95. 84<br />Source: NE YTS and YRBS, Tax Burden on Tobacco, 2011, and author’s calculations<br />
  96. 96. 85<br />Tobacco Taxation<br />Where are we now?<br />When tax last raised in 2002:<br /><ul><li>64 cent per pack was 17thhighest
  97. 97. About 10% above the average state tax rate
  98. 98. Currently:
  99. 99. 38th among state taxes
  100. 100. Majority of states have increased cigarette taxes since 2002, some multiple times
  101. 101. NE less that ½ of the average state tax
  102. 102. Have similarly fallen behind on other tobacco product taxes</li></li></ul><li>State Cigarette Excise Tax Rates – 2002<br />WA<br />VT<br />MT<br />ME<br />ND<br />OR<br />MN<br />NH<br />ID<br />WI<br />MA<br />NY<br />SD<br />WY<br />MI<br />RI<br />PA<br />IA<br />CT<br />NV<br />NE<br />NJ<br />OH<br />IL<br />IN<br />UT<br />DE<br />CA<br />WV<br />CO<br />VA<br />MD<br />KY<br />KS<br />MO<br />D.C.<br />NC<br />TN<br />AZ<br />OK<br />SC<br />NM<br />AR<br />$2.00+ per pack<br />GA<br />AL<br />MS<br />$1.50-$1.99 per pack<br />LA<br />TX<br />AK<br />$1.00-$1.49 per pack<br />FL<br />50-99 cents per pack<br />HI<br /><50 cents per pack<br />CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <br />
  103. 103. State Cigarette Excise Tax Rates – 2010<br />WA<br />VT<br />MT<br />ME<br />ND<br />OR<br />MN<br />Chicago$3.66<br />NH<br />ID<br />WI<br />MA<br />NY<br />SD<br />WY<br />MI<br />RI<br />PA<br />IA<br />CT<br />NV<br />NE<br />NJ<br />OH<br />IL<br />NYC<br />$5.85<br />IN<br />UT<br />DE<br />CA<br />WV<br />CO<br />VA<br />MD<br />KY<br />KS<br />MO<br />D.C.<br />NC<br />TN<br />AZ<br />OK<br />SC<br />NM<br />AR<br />≥ $3.00 per pack<br />GA<br />AL<br />MS<br />$2.00-$2.99 per pack<br />LA<br />TX<br />$1.50-$1.99 per pack<br />AK<br />FL<br />$1.00-$1.49 per pack<br />Anchorage<br />$3.45<br />HI<br />50-99 cents per pack<br /><50 cents per pack<br />CDC, Office on Smoking and Health. State Tobacco Activities Tracking and Evaluation (STATE) System. <br />87<br />
  104. 104. 88<br />Tobacco Taxation<br />Where can we go?<br />Raise the state cigarette excise tax<br /><ul><li>Getting back to 17thplace would require $1.70 per pack tax
  105. 105. If raised to $1.99 (15th highest):
  106. 106. Over $90 million in additional tax revenues in first full year; $10 million more from OTP increase
  107. 107. Almost 10,000 adult smokers would quit
  108. 108. Almost 19,500 fewer kids would start
  109. 109. Prevent about 8,8000 premature deaths from smoking among current population</li></li></ul><li>
  110. 110. 90<br />Tobacco Taxation<br />Where can we go?<br />Impose floor tax when adopting tax increases<br />
  111. 111. 91<br />Tobacco Taxation<br />Where can we go?<br />Raise the state’s other tobacco product excise taxes<br /><ul><li>Currently 20% of wholesale prices
  112. 112. By comparison, WI is 100% of wholesale price
  113. 113. Tighten tobacco product definitions</li></li></ul><li>92<br />Tobacco Taxation<br />Little cigars<br />Taxed at lower rate<br />Exempt from various product regulations related to flavorings, packaging, marketing<br />Can redefine cigarettes to include:<br />“any roll of tobacco that weighs no more than four and a half pounds per thousand (unless wrapped in whole tobacco leaf and does not have a cellulose acetate or other cigarette-like filter<br />Redefine cigars as <br />“any roll of tobacco <br />that is not a cigarette”<br />Source: Eric Lindblom, Campaign for Tobacco-Free Kids<br />
  114. 114. 93<br />Tobacco Taxation<br />Other product definitions<br />Non-combustible tobacco products – redefine smokeless tobacco products (or ‘other tobacco products’, ‘tobacco products’ to include:<br />“any other product containing tobacco that is intended or expected to be consumed without being combusted”<br />Source: Eric Lindblom, Campaign for Tobacco-Free Kids<br />
  115. 115. 94<br />Tobacco Taxation<br />Where can we go?<br />Allow for annual administrative tax increases to keep pace with inflation<br />
  116. 116. 95<br />Tobacco Taxation<br />Where can we go?<br />Use portion of new revenues to fund state tobacco control program<br />
  117. 117. 96<br />Tobacco Taxation<br />Where can we go?<br />Adopt high tech tax stamp and license all involved in tobacco distribution<br />Expand enforcement efforts<br />California – only state so far; generated additional $124 million in revenues in first 20 months <br />
  118. 118. 97<br />State of Tobacco Control in Nebraska<br />
  119. 119. 98<br />Summary<br />Harry Truman:<br />Give me a one-handed economist!<br /> All my economists say<br />On the one hand……<br />And on the other….<br />
  120. 120. 99<br />Summary<br />On the one hand, some positives<br />Continuing declines in tobacco use among adults and youth<br /><ul><li>Comparable to US and neighbors
  121. 121. One of the most comprehensive state smoke-free air policies in the world
  122. 122. Additional local policies thanks to absence of pre-emption</li></li></ul><li>100<br />Summary<br />On the other hand, several negatives<br />Persistent disparities in tobacco use<br />Woefully underfunded state tobacco control program<br />Have fallen well behind most states on tobacco taxes<br />
  123. 123. 101<br />Summary<br />And on the other other hand, some opportunities<br />Increased taxes on all tobacco products<br />Inflation adjustments, high-tech tax stamps, and increased enforcement<br />Funding for state tobacco control efforts<br />Comprehensive restrictions on tobacco company marketing<br />
  124. 124. For more information:<br /><br /><br /><br />